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Official Registration Form +:alifornia Water Resources Control Boar Hazardous Substance Storage Statement Who Must File: Each person storing hazardous substances in any under- the tank.Wastes are includetl, ground container must file this form no later than July 1, 1984(After October Fee: For each tank registered a3tCk'aik'; p;1}B,;p9iq, except that retail 1. 1984 and no later than January 1. 1985 for tanks used on farms). gasoline stations pay $5 per tank. Definition of Underground Containers: The law applies to "concrete Penalties: For failure to tile,the penalty is$500-$5,000 per day.If you falsify sumps, nonvaulted burled tanks or other underground containers.' (Water intonation, you can be lined up to$20,000 for.each day the information is Code section 13173) All containers, including earthen walled pitsponds. incorrect and has not been corrected lagoons and sumps, that are below the normal ground surface level must Confidentiality: If you have Information protected by trade secret laws. register. A tank sitting on the ground is not includetl. Containers partially please attach a list of the information on this form that is confidential and the beneath the surface are included Lined or unlined pits,ponds and lagoons are covered if earth has been removed from the storage area to construct justification for confidentiality, Including specific citations of relevant statu- the facility. Normal grading is not considered construction below ground tory and case law. level Multiple Containers: Fill I and 11 on one form and leave it blank on all the Definition of Hazardous Substance: Any substance listed in Section 6382 remaining forms. Attach all forms together securely. If you own more than of the Labor Code or in Section 25316 of the Health and Safely Code.This 50 tanks you can file information on computer tape. Call 916/324-1262 for . includes: gasoline, diesel fuel, all industrial solvents, pesticides. herbicides information. and fumigants. 11 the material must be carried by a registered hauler, dis- This Is not a Permit Application. All Underground Tanks will be subject to posed of at a hazardous waste site,is explosive,generates pressure due to local regulation. Some lunsdictions have already begun programs. Check heat or decomposition or would harm humans or wildlife you must register with your local county government for further information NOTE: ALL UNDERGROUND CONTAINERS MUST REGISTER EVEN IF STATE AND/OR LOCAL PERMITS ARE IN FORCE. I Owner Nidoeccawauon In(Lvqudl or Now A,vncyl The Church of Jesus Christ of Latter Day Saints (Seventh Floor) ' Slreei Adbess City Slate LIP 50 Fast North Temple St Salt Lake City Ut 84150 II Facility FacAly Name Doaler�Fwemary Sor+ermsor Stockton Bishops Storehouse Martin Avila Street Aawess NBeresl Goss street 3112 Loomis Road W. 99 Frontage Coy Cuuw, ZIP Stockton San Joaquin 95205 taa,rne:.Oars.,. Cn, State ZIP Same ca Phone w.'.xea'I'd, TYPe a Bush. (209) 943-1892 it or Motor Vehicle Fuel Station 0 o2 Other: Numoer co re:p at Irs racanv Rural Area. Townshq _ _ Flmge 1 Only: III 24 Hour Emergency Contact Person F5.-Y. Name Ila4 nartrB teals and Phone,,", code Ny ,s Name last nBnM bsll araC as r T4a-V Avila �z09) 943-1892 n Marin Avila (2o9) + +-1996 COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER IV Description -- CdnUlmr Numw pt emre rs do numaer ass,gn ones A.P m Tank 002 Sump Doi Lagoon, Pit or Pond 0 04 Other: 08601 B. Manufacturer(it appropriate): Year of Mfg.: 1980 C. Year Installed: 1981 .0 Unknown 0. Container Capacity:12i000 gallons 0 Unknown E Container Repairs: M ut None 0 w Unknown 0 os Yes Year: p vontainer currently used? INm Yes 002 No It No, year of last use: — 003 Unknown G. Does the Container Store (Check One): 0 or Waste IR o2 Product H. Does the Container Store Motor Vehicle Fuel or Waste Oil? 6 or Yes 0 w No If Yes, Check appropriate box(es): Doi Unleaded 0 02 Regular 0 03 Premium AM Diesel 0 os Waste Oil 0 de Other(List): V Container Construction ift A& w Mir i A Thickness of Primary Containment ___ ____._0 Gauge 0 Inches 0 cm X) Unknown i B. 0 or Vaulted (Located in an underground Vault.) 0 oz Non-vaulted XI u Unknown AllkAdk C. Dor Double Walled 002 Single s. ed 003 Lined 0oa Wrapped ®ds Unk wn 00o None D. Do, Carbon Steel 0 02 Stainless Steel 0 do Fiberglass 0 04 Polyvinyl Chloride 0 05 Concrete 0 oe Aluminum 0 or Steel Clad 0 as Bronze 0 ea Composite Do Non-metallic 0 it Earthen Walls LXr2 Unknown 0.3 Other: - -------- — E. Doi Rubber Lined 0 03 Alkyd Lining 0 on Epoxy Lining 0 o4 Phenolic Lining D us Glass Lining 0 m Clay Lining D or Unlined w Unknown 0 w Other. F Dor Polyethlene Wrap 0 02 Vinyl Wrapping 0 a Cathodic Protection JP u+ Unknown 0 os None 0 oa Other.